Psychotherapy for OCD

For people suffering from OCD, it can be hard to find help. Being an informed consumer can make all the difference.

It is common for people who think they might have OCD to say, "I'd better see someone," and go to see a psychotherapist. So far, so good. However, there are different types of therapy for OCD, and evidence suggests that some work better than others. Many people who seek help for obsessions or compulsions with a psychotherapist find that sometimes, after months or years of therapy, their symptoms are still a problem. There can be many possible reasons for this.

One possibility is that OCD is not the only problem that the patient has. Other co-occurring conditions (e.g., depression, eating disorders) can worsen prognosis.

Another possibility involves the fact that even the most effective treatments for OCD don't work for everyone. Exposure and Ritual Prevention (ERP), a kind of psychotherapy for OCD, is often found to produce significant improvement in two thirds to three quarters of patients in clinical research studies (e.g, as described in a previous post). This means that a significant proportion of people trying this type of therapy will not see significant improvement.

The most alarming possibility, perhaps, is that the patient sees no improvement, and is not receiving the appropriate type of therapy. Many people have called me over the years saying that they are contemplating switching therapists. When asked why, they often say something like, "Well, I really like my therapist and all, but we've been talking about my childhood and my parents for 2-3 years now, and I'm still checking my kitchen stove 30 times a day. I'm getting tired of it!" If you think you may have OCD and decide to see a therapist to work on it, ask them whether they recommend ERP for you. They may have a good reason for not recommending it; however if they're not familiar with it, you might consider seeking out a second opinion.

How to Find a Therapist

Finding a therapist can be a confusing task. Where to start? Should you ask your doctor? Look on the internet? Ask a friend? Ask your insurance company?

These are all reasonable ideas on the face of them. However, some strategies may be more practical for you than others. Let's look at each of the above options.

If you have a good relationship with your primary care doctor, and feel comfortable asking him or her for a referral, than this may be a helpful step. Even if he or she does not have any suggestions for you, it can't hurt. If your doctor does give you some referrals, it is helpful to be an informed consumer and find out whether the names you are given are psychiatrists, psychologists, or other types of mental health professionals. Your doctor may be more likely to recommend a psychiatrist than other professionals, since they share a common training background. However, a psychiatrist may or may not be the right fit for you. If you are looking to meet with someone who can prescribe medications for your condition, psychiatrists are typically the best option. However, if you are looking for weekly psychotherapy, seeing a psychiatrist may prove to be less appropriate (or affordable) than some other options.

What about looking on the internet for a therapist? We search on the internet for so many things, why not therapists too? In fact, this can be a very helpful step to take. There are several "find-a-therapist" sites available at no charge on the internet. As described in an article on this topic from 2008, it can be helpful to educate yourself on which types of therapist are appropriate for your problem(s). If, for example, you have decided to pursue cognitive-behavioral therapy, I would recommend the therapist finder at http://www.abct.org -- just go to that website and click on "Find a Therapist." This service is provided by the Association for Behavioral and Cognitive Therapies, and organization serving the U.S. and Canada. If you're not yet sure which type of therapy would be best for you, you can peruse the listings at http://www.psychologytoday.com by clicking on "find a therapist" at that website. This resource is also only for those in the U.S. and Canada. For users in the U.K., I would recommend http://www.counselling-directory.org.uk/.

What about asking a friend for a referral? Some readers will be immediately uncomfortable with this idea, but for others, it can be helpful; however this option is somewhat perilous as your friend may assume that what is helpful for them will be helpful for everyone else, including you. This may not be true. For this reason alone, I recommend this option less than any of the others described in this posting. Additionally, if you get a therapist recommendation from your friend, and decide to see that therapist, then you have created the potentially awkward situation of your friend(s) knowing you are in therapy. You may even end up running into them in the waiting room! Only choose this option if you are not bothered by these potential problems.

For those of you who want to use an in-network provider for your insurance company, it may be that none of the above options will work for you, because many providers will not be in your network. In this case, I typically recommend that you contact your insurance company and ask them which providers are in-network, and in your area. Many insurers post this information on their own websites. If you are seeking a specific type of therapy, let your insurance company know. For example, if you are seeking Exposure and Ritual Prevention therapy for OCD, and if you have trouble finding a therapist competent with this type of therapy in your network, don't be afraid to call your insurance company and ask them to recommend someone. They may do just that, or may extend you in-network benefits for an out-of-network provider if none of their therapists have the necessary expertise. Unfortunately, the insurance company may have no recommendations, and just wish you good luck; you won't know unless you call them and see.

September 11th and Anxiety

For those of us who were living in New York or Washington on September 11th, 2001, and for those of us who were otherwise affected by the events of that day, each anniversary of that date can bring its own difficult memories. It is not uncommon for those who were affected by 9/11 to experience an increase in certain unpleasant symptoms on anniversaries of 9/11/01. These can include troubling memories, dreams or nightmares, anxiety, avoidance of reminders of 9/11, feeling emotionally “numb,” depression, or increased alertness (sometimes described as feeling overly “on guard”). These are symptoms of posttraumatic anxiety. For some people, these symptoms get worse over time, but for others they improve. For many, drug and alcohol use emerge as a way to cope with the symptoms.

The New York City Health Department is sponsoring a program to help people suffering from these symptoms. This program (see http://www.nyc.gov/9-11mentalhealth) pays for psychotherapy for persons who were affected by 9/11, even if only indirectly. This program is only for current residents of New York City. If you have some of the symptoms described above and have not already sought help, consider this program. While seeking help can sometimes be a hard step to take, it’s never too late to address posttraumatic anxiety.

CBT becoming more available in the U.K.

Starting in 2006, the British government undertook an initiative to make high quality psychotherapy more widely available for people suffering from depression, anxiety, and related problems. While many different types of psychotherapy were already available, the government chose to make therapies proven to be effective available to as many patients as possible. Cognitive behavioral therapy is one example of a psychotherapy that the British government is attempting to make more widely available.

UK Health Secretary Alan Johnson was quoted in a recent BBC article saying that "For many people prescribing medication is a successful treatment but we know that psychological therapies work equally well."

In making decisions about whether to undertake a treatment of medication, psychotherapy, or both, it is important to educate yourself about which treatments have been proven effective through research studies. Fortunately, the FDA restricts use of psychopharmacological medications to problems for which a particular drug has been demonstrated to be effective. Fortunately or unfortunately, psychotherapies are not regulated by any government agency, and thus it is especially helpful to get as much information as you can about which type of psychotherapy is helpful for your particular issue. One recommendation I have is to ask a prospective psychotherapist what kind of therapy they would use with you, given your symptoms. They may insist on an in-person consultation before answering this question, which is appropriate. Another recommendation is to ask a prospective psychotherapist whether there is research to suggest that this particular kind of therapy is effective for your particular problem.

Given all the research that has been done to determine which types of psychotherapy are helpful for particular problems, psychotherapists are now able to more easily determine which type of psychotherapy is likely to be beneficial in given situations. Help yourself by asking your therapist what research there is to support their particular approach for a given problem.

Mindfulness in therapy

An article in the New York Times health section today, entitled "Lotus Therapy," describes the increasingly prevalent use of mindfulness techniques in psychotherapy over the past ten years. The article describes the state of research on the use of mindfulness meditation as "thin," and indeed the evidence for the effectiveness of mindfulness' use for anxiety and depression is not as substantial as the evidence for cognitive-behavioral therapy or antidepressant medication. However, the research that has been conducted to this point paints a picture of mindfulness meditation as a useful tool -- for those inclined to use it -- in fighting depression and anxiety.

A fair consideration of the strength of evidence for mindfulness meditation vs. psychotherapy and pharmacological treatments should keep in mind a few key points:

1) Few people make the claim that mindfulness meditation is an appropriate substitute for either cognitive-behavioral therapy or for medication. Typically it is described as an important complement to psychotherapy. Comparing its effectiveness to that of either of the other two treatment modalities sets up a false dichotomy.

2) The use of mindfulness in psychotherapy has become widespread only relatively recently, and thus has not had the benefit of decades of research studies to support its effectiveness. As mentioned in the Times article, there is an increasing effort being made to include mindfulness in NIH-funded research studies.

Challenges to seeking help

A recent New York Times article highlighted the difficulty many people face in deciding whether or not to seek help for emotional problems – readable at http://www.nytimes.com/2008/04/18/us/18vets.html. The article describes a recent privately conducted research study that concluded that 19% of the 1.6 million members of the American military who have recently served in Iraq or Afghanistan have symptoms of posttraumatic stress disorder or major depression. Of the 19%, however, only slightly more than half have sought help.

There are many reasons that people are reluctant to seeking help for emotional difficulties. One reason is the commonly held belief that one should be able to handle whatever life throws one’s way, and that seeking help is akin to cheating, or to admitting defeat. Many people truly, deeply believe that the problems they are experiencing are their own fault, and thus, it would wrong to seek help. While it may be true that they have contributed to these problems, it is often untrue that seeking help would be a copout. For example, let’s say that you had a close friend who started to drink too much. Let’s say this drinking became a problem in their lives, and affected your friend’s relationships and work. Fortunately, your friend recognized that the drinking had become problematic, but blamed themselves for “letting things get to this point” and insisted that cutting back on drinking was the only answer to their problems – “simple as that.” Wouldn’t you want your friend to at least try to seek help, even if they ultimately decided that it wasn’t for them?

Ultimately, whatever change does happen in psychotherapy occurs because of changes made by the person themselves, regardless of any guidance from a therapist.

Another factor that plays into reluctance to seek help is described very well in the New York Times article – fear of one’s employer finding out, resulting in negative consequences. In the case of the military, servicemen and women are typically aware that their commanding officer has access to their full medical records, which would include any mental health services received, especially those received from the U.S. Military health system. For people outside of the military, working in the private sector, there are often similar fears. A typical source of these concerns is the question of whether a company’s human resources departments can obtain personal health information from the health insurer. Unfortunately there is often little information available about how justified this concern may be.

CBT for OCD

For many sufferers of Obsessive-Compulsive Disorder (OCD) and other types of anxiety, deciding to seek help can be a difficult decision to make. Once that decision is made, another choice is required: what kind of help is best for me? Two of the most researched treatment options available are pharmacological treatment (medication) and cognitive-behavioral therapy. Many people will prefer one or the other, saying, “Oh, I would never want to take medication unless I had to,” or alternatively, “Just give me the pill, what’s the big deal?” This is a very personal choice that each person must make individually. For those that wonder how effective each option may be for them, good news – there is a good deal of research on exactly how effective each of these two treatment options can be.

Much of the research on the effectiveness of various medications for OCD focuses on the class of medications known as the SSRIs (selective serotonin reuptake inhibitors). This class of medications is relatively new, having been first used in the late 1980’s. Medications like Celexa, Lexapro, Prozac, Zoloft, Luvox, and Paxil belong to this class. They are widely used, partially because their side effect profiles are favorable. Some possible side effects are difficulties with sexual arousal, lowered interest in sex, headache, and changes in appetite. However each medication will have a different set of potential side effects, and of course you should consult your prescriber before deciding which medication might be best for you.

Much of the research on the effectiveness of psychotherapy for OCD and anxiety disorders focuses on different types of cognitive-behavioral therapy (CBT). For OCD, a form of cognitive-behavioral therapy known as Exposure and Ritual Prevention (ExRP) has been shown to be effective in treatment. ExRP is the updated form of Exposure and Response Prevention (ERP), and it focuses on changing the strategies used by the OCD sufferer to cope with anxiety. For more on ExRP, click here.

Both SSRI and CBT are considered first-line treatments for simple OCD, meaning that one of the two will typically be the first thing recommended for someone with OCD. Research has generally not shown either one to be more effective than the other; both are considered effective in reducing symptoms of COD. Occasionally there is research that compares these two types of OCD treatment, and a study was published in July 2006 that did just that. Some researchers in Brazil compared Zoloft to a CBT group therapy. CBT group therapy for OCD has been shown to be comparably effective to individual CBT for OCD. In the Brazilian study, a summary of which is included below, the CBT that was studied included “techniques of ERP” as well as some classic elements of CBT. While details were not explicit in the article, the therapy used may be best understood as a hybrid of ERP and conventional CBT.

Here is the summary, as reported in 2006 by Reuters:

OCD Responds Better to Cognitive-Behavioral Therapy Than to Sertraline

NEW YORK (Reuters Health) Aug 28 - Combination treatment withcognitive-behavioral group therapy plus sertraline (Zoloft) is effective for the treatment of obsessive-compulsive disorder (OCD), but when each treatment is given alone, cognitive-behavioral therapy is superior to sertraline. Although OCD is responsive to the combination of these two therapeutic approaches, Dr. Aristides V. Cordioli and colleagues from Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, wrote, "there is no consensus about which of these forms of treatment is more effective" when used alone.

In the current study, published in the July issue of the Journal of Clinical Psychiatry, the researchers compared the efficacy of cognitive behavioral therapy versus sertraline in reducing symptoms of OCD. They evaluated 50 OCD outpatients randomized to 100 mg/day sertraline or cognitive behavioral group therapy for 12 weeks. The patients were assessed at baseline and weeks 4, 8, and 12.

While the patients responded to both treatments, "the reduction of symptoms for cognitive behavioral group therapy patients was 44.07% while in the sertraline group it was 27.78% (p = 0.033)," Dr. Cordioli's team reports.

Patients who received cognitive behavioral group therapy also experienced asignificantly greater reduction in the intensity of compulsions (p = 0.030).

Complete remission of OCD symptoms was observed in eight patients in the cognitive behavioral therapy group compared with only one patient in the sertraline group.

No significant reductions in the intensity of anxiety and depression symptoms were seen with either treatment.

This study showed that the group receiving CBT experienced greater reduction in symptoms than the group receiving Zoloft. The authors point out that the study was conducted on patients suffering from OCD but not from any other psychological problems (e.g., depression, social anxiety), and that the results obtained in the study may not apply to people with other difficulties in addition to OCD. This study can be interpreted as confirmation of the effectiveness of both CBT and Zoloft in treatment of OCD, and also as showing some newer results about the superiority of CBT in the “intensity of compulsions, the rate of symptom reduction, and in complete remission.”

Some people with OCD wonder about the advisability of taking medication while in therapy. There are advantages and disadvantages to this. One advantage to not taking any psychoactive medication while in CBT is that you will learn new skills to cope with your OCD, anxiety, depression, etc., while you are experiencing those symptoms. If you began CBT while on medication, and then later came off the medication, your symptoms may overwhelm your ability to use the tools you had learned in CBT. Some people report that while medication is helpful for them, it is not helpful anymore after they stop taking it, and they are vulnerable to feeling that they are “back at square one.”

There has been other recent research on the neurophysiology of OCD that shows differences in brain activity patterns in people with OCD compared to people without OCD. Research has also found that these patterns change after successful CBT or SSRI treatment. While some sufferers of OCD may be alarmed at the notion that their brains are different than anyone else’s, it is important to remember that the brain is a remarkable, dynamic, constantly changing organ. Every time we learn something new, nerve cells in our brains form new and different connections that were not there before. Patterns of activity in the brain change when we perform seemingly simple tasks: every time we open our eyes in the morning, a complex wave of electrical activity makes its way from our optic nerve to various parts of our cerebral cortex. Given the sensitivity of the brain to new information and new habits (both mental and physical), it should not be a surprise, nor undue cause for alarm, that patterns of activity in the brain should be different in people with OCD. Some interpret research studies on the effects of CBT and medication on the brain as simply complementary to other studies showing the effectiveness of these treatment options.

In conclusion, the choice of whether to pursue CBT, medication, or both can be a difficult one. Fortunately, sufferers of OCD today can take some comfort in the fact that both of these treatments have been shown to be effective, as neither was available just a few decades ago.

New research on depression

A recent study in the Archives of General Psychiatry examined the relationship between our thoughts and our mood. In the July 2006 issue, Zindel Segal and colleagues from the University of Toronto and the Centre for Addiction and Mental Health in Toronto write about a study they conducted on people with a history of recurrent depression. Their results showed that for those with recurrent depression but who are currently not depressed, the more a sad mood influences their thought patterns, the more vulnerable they will be to further depression.

Participants in this research study were randomly assigned to receive either antidepressive medication or cognitive-behavioral psychotherapy. One interesting result the study's authors found was that those participants receiving the cognitive-behavioral therapy had less "cognitive reactivity" to sad mood than those participants who received medication. This means that for those people receiving the cognitive-behavioral therapy, their thoughts were less influenced by a sad mood than was the case for those who received the antidepressant treatment.

It is generally accepted that cognitive-behavioral therapy or antidepressant medication, or both, are effective treatments for depression. However the choice between these two treatment options can be difficult for many people. Often it comes down to personal preference. Some people are reluctant to go on medications for various reasons. Others are reluctant to enter psychotherapy. Research has shown both types of treatment to be effective for depression, and can help people struggling with depression to create some positive changes in their lives.

The above-mentioned study found one interesting difference between these two treatments, however. People who received antidepressant medication experienced greater changes in their thought patterns than those who had received the cognitive-behavioral therapy. This is a relevant finding because we know that thought content can be either a cause or effect of depressed mood. For example, if someone is often having thoughts like "I'm a bad person" or "I'm no good at anything" or "Something is bound to go wrong today," these thoughts will quite likely have an eventual effect on the person's mood. This effect can be greater or lesser depending on the exact content of the thoughts, and other factors. However if a brief sad mood effects your thought patterns very significantly, you may be more likely to experience a relapse of depression, especially if you have a history of depression. This study suggests that those participants who received the cognitive-behavioral therapy were more resistant to negative changes in their thought patterns. While the study did not investigate why people in cognitive-behavioral therapy fared better in this way, it does make some intuitive sense. Cognitive-behavioral therapy teaches how to recognize and rationally evaluate thoughts that may be contributing to depression (or anxiety). It may be that the people who received cognitive-behavioral therapy were better able to recognize early changes in thought patterns, and prevented those changes from becoming more pronounced by taking a more balanced perspective on the depressive thoughts.